Successful combinations of drug and non-drug therapy for low back pain

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Low back pain (LBP) is one of the most common complaints with which patients are consulted by neurologists and therapists every day. Therefore, knowledge and ability to correctly diagnose and treat patients with LBP are integral professional skills of a neurologist and therapist. Clinical cases of management of patients with LBP are described. A modern and effective approach to the diagnosis and treatment of LBP associated with musculoskeletal disorders and discogenic radiculopathy is presented. Shown are the typical, most common red and yellow flags found among patients with LBP. Typical comorbid disorders in LBP and the importance of their timely diagnosis and treatment are demonstrated. To treat patients with chronic musculoskeletal LBP, a comprehensive approach was used, including educational conversations about the disease, kinesiotherapy, and a course of pharmacotherapy with a nonsteroidal anti-inflammatory drug (NSAID) and a muscle relaxant for 14 days. The drugs of choice were aceclofenac and long-acting tolperisone. A comprehensive, multi-stage approach was used to treat a patient with acute lumbar ischialgia and discogenic radiculopathy. From the first days of treatment, an educational conversation was held about the disease, recommendations were given on physical activity, and aceclofenac and long-acting tolperisone were prescribed for 14 days. From the second week of treatment, due to persistence of intense pain associated with radiculopathy, gabapentin was prescribed. After 14 days, after the pain subsided, kinesiotherapy was added to the treatment. In all of the described patients, by the 3rd month of treatment, pain regressed and daily activity returned to normal. By the 6th month of observation, the achieved results were maintained.

Keywords:

low back pain

lumbar ischialgia

musculoskeletal pain

discogenic radiculopathy

diagnosis

treatment

kinesiotherapy

therapeutic exercises

pharmacotherapy

aceclofenac

tolperisone

gabapentin

Authors:

Golovacheva V.A.

Sechenov First Moscow State Medical University (Sechenov University)

ORCID: 0000-0002-2752-4109

Golovacheva A.A.

Sechenov First Moscow State Medical University (Sechenov University)

ORCID: 0000-0002-2845-7323

Received:

25.01.2024

Accepted:

30.01.2024

List of references:

Walker BF. The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205-217. 10.1097/00002517-200006000-00003
Parfenov VA, Yakhno NN, Kukushkin ML, Churyukanov MV, Davydov OS, Golovacheva VA, Isaikin AI, Achkasov EE, Evzikov GYu, Karateev AE, Khabirov FA, Shirokov VA. Acute nonspecific (musculoskeletal) low back pain Guidelines of the Russian Society for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics. 2018;10(2):4-11. (In Russ.). https://doi.org/10.14412/2074-2711-2018-2-4-11
Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Schorr SG. Non-Specific Low Back Pain. Dtsch Arztebl Int. 2017;114(51-52):883-890. https://doi.org/10.3238/arztebl.2017.0883
Maher C, Ferreira G. Time to reconsider what Global Burden of Disease studies really tell us about low back pain. Ann Rheum Dis. 2022;81(3):306-308. https://doi.org/10.1136/annrheumdis-2021-221173
Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. https://doi.org/10.1177/0333102417738202
Parfenov VA, Yakhno NN, Davydov OS, Kukushkin ML, Churyukanov MV, Golovacheva VA, Isaikin AI, Achkasov EE, Evzikov GYu, Karateev AE, Khabirov FA, Shirokov VA, Yakupov EZ. Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics. 2019;11(2S):7-16. (In Russ.). https://doi.org/10.14412/2074-2711-2019-2S-7-16
Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J; EFNS. EFNS guideline on the treatment of tension-type headache — report of an EFNS task force. Eur J Neurol. 2010;17(11):1318-1325. PMID: 20482606. https://doi.org/10.1111/j.1468-1331.2010.03070.x
Poluektov MG, Buzunov RV, Averbukh VM, Verbitsky EV, Zakharov AV, Kelmanson IA, Korabelnikova EA, Litvin AYu, Palman AD, Rusetsky YuYu, Strygin KN, Yakupov EZ. Project of clinical recommendations on diagnosis and treatment of chronic insomnia in adults. Consilium Medicum. Neurology and Rheumatology (Suppl.). 2016;2:41-51. (In Russ.). https://www.rnmot.ru/public/uploads/2020/RNMOT/%D0%9A%D0%BB%D0%B8%D0%BD%D0%B8%D1%87%D0%B5%D1%81%D0%BA%D0%B8%D0%B5%20%D1%80%D0%B5%D0%BA%D0%BE%D0%BC%D0%B5%D0%BD%D0%B4%D0%B0%D1%86%D0%B8%D0%B8%20%D0%BF%D0%BE%20%D0%B8%D0%BD%D1%81%D0%BE%D0%BC%D0%BD%D0%B8%D0%B8.pdf
Parfenov VA, Yakhno NN, Davydov OS, Kukushkin ML, Churyukanov MV, Golovacheva VA, Evzikov GYu, Isaikin AI, Ivanova MA, Karateev AE, Amelin AV, Achkasov EE, Akhmadeeva LR, Bakhtadze MA, Barantsevich ER, Barulin AE, Belova AN, Belskaya GN, Bychenko VG, Doronina OB, Dreval ON, Zagorulko OI, Isagulyan ED, Iskra DA, Kalinsky PP, Karakulova YuV, Kurushina OV, Medvedeva LA, Merkulova DM, Rachin AP, Sergienko DA, Strokov IA, Khabirov FA, Shirokov VA, Yakupov EZ. Discogenic lumbosacral radiculopathy. Recommendations of the Russian Association for the Study of Pain (RSSP). Neurology, Neuropsychiatry, Psychosomatics. 2020;12(4):15-24. (In Russ.). https://doi.org/10.14412/2074-2711-2020-4-15-24
Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC 3rd, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O’Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL Jr, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. 2020;20(7):998-1024. https://doi.org/10.1016/j.spinee.2020.04.006
Golovacheva VA, Golovacheva AA, Fateeva TG. Clinical principles for the diagnosis and treatment of musculoskeletal (non-specific) lower back pain. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(3):107-112. (In Russ.). https://doi.org/10.14412/2074-2711-2021-3-107-112
Golovacheva AA, Golovacheva VA, Parfenov VA. Kinesiotherapy and non-steroidal anti-inflammatory drugs for nonspecific lumbago. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(1):89-96. (In Russ.). https://doi.org/10.14412/2074-2711-2022-1-89-96
Zinovyeva OE, Golovacheva AA. Cognitive functional therapy and non-steroidal anti-inflammatory drugs in the treatment of low back pain. Meditsinskiy sovet = Medical Council. 2022;23:78-85. (In Russ.). https://doi.org/10.21518/2079-701X-2022-16-23-78-85
Isaikin AI, Nasonova TI. Muscular factor in the development of musculoskeletal pain. Treatment options. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(2):98-104. (In Russ.). https://doi.org/10.14412/2074-2711-2022-2-98-104
Golovacheva VA, Tabeeva GR, Golovacheva AA. Non-specific low back pain: principles and algorithms for successful management of patients in real clinical practice. Neurology, Neuropsychiatry, Psychosomatics. 2023;15(3):85-94. (In Russ.). https://doi.org/10.14412/2074-2711-2023-3-85-94
Golovacheva VA, Tabeeva GR, Fateeva TG. Management of patients with musculoskeletal back pain and comorbid anxiety. Meditsinskiy sovet = Medical Council. 2022;23:60-66. (In Russ.). https://doi.org/10.21518/2079-701X-2022-16-23-60-66
Golovacheva AA, Golovacheva VA. Kinesiotherapy in chronic back pain and combined tension type headache. Russian Neurological Journal. 2023;28(3):61-68. (In Russ.). https://doi.org/10.30629/2658-7947-2023-28-3-61-68
Karateev AE, Nasonov EL, Ivashkin VT, Martynov AI, Yakhno NN, Arutyunov GP, Alekseeva LI, Abuzarova GR, Evseev MA, Kukushkin ML, Kopenkin SS, Lila AM, Lapina TL, Novikova DS, Popkova TV, Rebrov AP, Skorobogatykh KV, Chichasova NV. Rational Use Of Nonsteroidal Anti-Inflammatory Drugs. Clinical Guidelines. Rheumatology Science and Practice. 2018;56:1-29. (In Russ.). https://doi.org/10.14412/1995-4484-2018-1-29
Hinz B, Rau T, Auge D, Werner U, Ramer R, Rietbrock S, Brune K. Aceclofenac spares cyclooxygenase 1 as a result of limited but sustained biotransformation to diclofenac. Clin Pharmacol Ther. 2003;74(3):222-235. https://doi.org/10.1016/S0009-9236(03)00167-X
Legrand E. Aceclofenac in the management of inflammatory pain. Expert Opin Pharmacother. 2004;5(6):1347-1357. https://doi.org/10.1517/14656566.5.6.1347
Lanas A, García-Rodríguez LA, Arroyo MT, Gomollón F, Feu F, González-Pérez A, Zapata E, Bástida G, Rodrigo L, Santolaria S, Güell M, de Argila CM, Quintero E, Borda F, Piqué JM; Asociación Española de Gastroenterología. Risk of upper gastrointestinal ulcer bleeding associated with selective cyclo-oxygenase-2 inhibitors, traditional non-aspirin non-steroidal anti-inflammatory drugs, aspirin and combinations. Gut. 2006;55(12):1731-1738. https://doi.org/10.1136/gut.2005.080754
Laporte JR, Ibáñez L, Vidal X, Vendrell L, Leone R. Upper gastrointestinal bleeding associated with the use of NSAIDs: newer versus older agents. Drug Saf. 2004;27(6):411-420. https://doi.org/10.2165/00002018-200427060-00005
Castellsague J, Riera-Guardia N, Calingaert B, Varas-Lorenzo C, Fourrier-Reglat A, Nicotra F, Sturkenboom M, Perez-Gutthann S; Safety of Non-Steroidal Anti-Inflammatory Drugs (SOS) Project. Individual NSAIDs and upper gastrointestinal complications: A systematic review and meta-analysis of observational studies (the SOS project). Drug Saf. 2012;35(12):1127-1146. https://doi.org/10.2165/11633470-000000000-00000
Karateev AE. Aceclofenac in rheumatology: The golden mean. Modern Rheumatology Journal. 2013;7(2):88-94. (In Russ.). https://doi.org/10.14412/1996-7012-2013-2389
Gontarenko NV, Tsurgan AV, Karateev AE. Treatment for acute/subacute musculoskeletal pain, by using an algorithm for stepwise choice of analgesic drugs and for monitoring their efficacy: Preliminary data of the Analgesic Treatment Using Systemic Algorithm (ATUSA) program. Modern Rheumatology Journal. 2016;10(4):35-40. (In Russ.). https://doi.org/10.14412/1996-7012-2016-4-35-40
Karateev AE, Tsurgan AV. Aceclofenac: the experience of Russian studies. Modern Rheumatology Journal. 2017;11(4):89-94. (In Russ.). https://doi.org/10.14412/1996-7012-2017-4-89-94
Yang JH, Suk KS, Lee BH, Jung WC, Kang YM, Kim JH, Kim HS, Lee HM, Moon SH. Efficacy and Safety of Different Aceclofenac Treatments for Chronic Lower Back Pain: Prospective, Randomized, Single Center, Open-Label Clinical Trials. Yonsei Med J. 2017;58(3):637-643. PMID: 28332372 PMCID: PMC5368152. https://doi.org/10.3349/ymj.2017.58.3.637
Schattenkirchner M, Milachowski KA. A double-blind, multicentre, randomised clinical trial comparing the efficacy and tolerability of aceclofenac with diclofenac resinate in patients with acute low back pain. Clin Rheumatol. 2003;22(2):127-135. https://doi.org/10.1007/s10067-003-0710-9
Lemmel EM, Leeb B, De Bast J, Aslanidis S. Patient and physician satisfaction with aceclofenac: results of the European Observational Cohort Study (experience with aceclofenac for inflammatory pain in daily practice). Aceclofenac is the treatment of choice for patients and physicians in the management of inflammatory pain. Curr Med Res Opin. 2002;18(3):146-53. https://doi.org/10.1185/030079902125000507
Tekes K. Basic aspects of the pharmacodynamics of tolperisone, a widely applicable centrally acting muscle relaxant. Open Med Chem J. 2014;8:17-22. https://doi.org/10.2174/1874104501408010017
Isaikin AI, Nasonova TI. Muscular factor in the development of musculoskeletal pain. Treatment options. Neurology, Neuropsychiatry, Psychosomatics. 2022;14(2):98-104. (In Russ.). https://doi.org/10.14412/2074-2711-2022-2-98-104
Caron J, Kaye R, Wessel T, Halseth A, Kay G. An assessment of the centrally acting muscle relaxant tolperisone on driving ability and cognitive effects compared to placebo and cyclobenzaprine. J Clin Pharm Ther. 2020;45(4):774-782. https://doi.org/10.1111/jcpt.13165
Prabhoo R, Keny S, Prabhoo T, Singh A, Rana R. A phase IV observational multi-centre, open-label study on efficacy and safety of tolperisone 150 mg in patients with painful muscle spasm associated with degenerative or inflammatory diseases of the musculoskeletal system. J Assoc Physicians India. 2011;59:33-37. PMID: 21751662. https://pubmed.ncbi.nlm.nih.gov/21751662
Rao R, Panghate A, Chandanwale A, Sardar I, Ghosh M, Roy M, Banerjee B, Goswami A, Kotwal PP. Clinical comparative study: efficacy and tolerability of tolperisone and thiocolchicoside in acute low back pain and spinal muscle spasticity. Asian Spine J. 2012;6(2):115-122. https://doi.org/10.4184/asj.2012.6.2.115
Csiba L, Zhussupova AS, Likhachev SA, Parfenov VA, Churyukanov MV, Guekht AB. A systematic review of using myorelaxants in treatment of low back pain. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2018;118(12):100-113. (In Russ.). https://doi.org/10.17116/jnevro2018118121100
Dulin J, Kovács L, Ramm S, Horvath F, Ebeling L, Kohnen R. Evaluation of sedative effects of single and repeated doses of 50 mg and 150 mg tolperisone hydrochloride. Results of a prospective, randomized, double-blind, placebo-controlled trial. Pharmacopsychiatry. 1998;31(4):137-142. https://doi.org/10.1055/s-2007-979315
Skoromets AA, Guekht AB, Galanov DV, Danilenko OA, Barantsevich ER, Lebedeva AV, Belova AN, Shprakh VV, Bogdanov EI, Prokopenko SV, Khabirov FA, Spirin NN, Baliazin VA, Miakotnykh VS, Volkova LI, Gafurov BG, Mishchenko TS, Toktomushev ChT, Shiralieva RK, Musaev SK, Guseinov SG. The results of the multicenter pharmaco-epidemiological observational project on the use of mydocalm in the treatment of pain syndromes with the muscle spasm. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2015;115(12):104-109. (In Russ.). https://doi.org/10.17116/jnevro2015115112104-109
Parfenov VA, Bogdanov EI, Laskov VB, Makarov NS, Pisova NV, Salina EA, Chefranova ZYu, Chichanovskaya LV. Multicenter, randomized, double-blind study of the efficacy and safety of prolonged release tolperisone hydrochloride 450 mg (Mydocalm® Long, once daily) and tolperisone hydrochloride 150 mg (three times daily) for acute non-specific lower back pain. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(6):14-22. (In Russ.). https://nnp.ima-press.net/nnp/article/view/1658
Moisset X, Bouhassira D, Avez Couturier J, Alchaar H, Conradi S, Delmotte MH, Lanteri-Minet M, Lefaucheur JP, Mick G, Piano V, Pickering G, Piquet E, Regis C, Salvat E, Attal N. Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations. Rev Neurol (Paris). 2020;176(5):325-352. Epub 2020 Apr 07. PMID: 32276788. https://doi.org/10.1016/j.neurol.2020.01.361
Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, Nurmikko T. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010;17(9):1113-e88. https://doi.org/10.1111/j.1468-1331.2010.02999.x
Gerasimova ON, Parfenov VA. Management of patients with back pain in outpatient practice. Neurology, Neuropsychiatry, Psychosomatics. 2010;2(4):65-71. (In Russ.). https://doi.org/10.14412/2074-2711-2010-120
Yildirim K, Deniz O, Gureser G, Karatay S, Ugur M, Erdal A, Senel K. Gabapentin monotherapy in patients with chronic radiculopathy: The efficacy and impact on life quality. J Back Musculoskelet Rehabil. 2009;22(1):17-20. PMID: 20023359. https://doi.org/10.3233/BMR-2009-0210
Kasimcan O, Kaptan H. Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. Neurol Med Chir (Tokyo). 2010;50(12):1070-1073. PMID: 21206180. https://doi.org/10.2176/nmc.50.1070
Levin OS, Moseĭkin IA. Efficacy of gabapentin in patients with discogenic lumbosacral radiculopathy. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2009;109(12):60-65. PMID: 20037523. (In Russ.).

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